1. Endovenous Treatment of Venous Diseases: Preprocedural assessment, indications and contraindications
Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS
Professor of Vascular Surgery
Faculty of Medicine, University of Thessalia, Greece
Chairman, Dept. of Vascular Surgery, University Hospital of Larissa
Larissa, Greece

2. GSV Before Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

3. GSV After Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

4. CEAP Clinical Classification
0: Asymptomatic; no visible or palpablesigns
1: Spider veins, reticular veins, telangiectasias
2: Varicose veins
3: Edema
4a: Skin changes with hyperpigmentation and eczema
4b: Skin changes with lipodermatosclerosis and atrophie blanche
5: Healed ulcer
6: Active ulcer 4

5. CEAP Clinical Classifications Clinical Etiology Anatomy Pathophysiology
Varicose Veins
CEAP 2
Swelling
CEAP 3
Skin Changes
CEAP 4
Skin Ulcer
CEAP 6

6. Is pre-op duplex assessment important for varicose vein surgery?

7. Ultrasonic assessment

8. Explanation
Information provided by DS will have significant impact on the selection of appropriate treatment
Failure to identify all sources of venous filling is likely to result in early recurrence

9. Indications for Duplex Scan
Recommendation: both limbs should be studied
Primary uncomplicated GSV VVs
Debated whether all pts – if not 30% of important connections between deep and superficial veins will be missed
Primary uncomplicated LSV VVs Essential
Non-saphenous & Recurrent VVs Essential
CVD with complications Essential
Surveillance after treatment the only way to obtain level I evidence as to outcome in the future
Venous malformations
anatomical information about the extent of the malformation and its relationship to other vessels
may be used to guide treatment by sclerotherapy

10. Position of the patient
Greater saphenous

11. Position of the patient
Lesser saphenous

12. Anatomy of superficial veins of the lower limb

13. Important anatomical details

14. Anatomical structures on B-mode

15. Fascial layers creating “saphenous eye”
GSV
Bound anteriorly by superficial fascia & posteriorly by deep fascia
Often called “saphenous eye”
Fascial layers creating “saphenous eye”
Images courtesy of Olivier Pichot, MD

16. GSV Variables Tortuosity Side branches
Images courtesy of Olivier Pichot, MD

17. GSV Variables
Aneurysmal segments

18. SFJ Tributary Veins SCI: Superficial Circumflex Iliac
SE: Superficial Epigastric
SEP: Superficial External Pudendal
AASV: Anterior Accessory Saphenous
PASV: Posterior Accessory Saphenous
Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53

21. Initial Catheter Tip Positioning
Position catheter tip approximately 2.0 cm distal to SFJ
Confirm with measurement calipers
Distance does not need to be precise at this time because catheter position may shift during tumescent fluid infiltration

22. Final Tip Position Verification
Recommendation is 2.0 cm distal to SFJ
Confirm tip position with ultrasound:
In both transverse and longitudinal imaging planes
Use measurement calipers to confirm distance to SFJ
Important step to avoid misaligning catheter relative to deep venous system
Image courtesy of Pranay Ramdev, MD
The final tip position of the catheter should be confirmed with duplex ultrasound to ensure the device is not in the deep venous system:
in transverse view from proximal thigh towards SFJ; Note transition where echogenic dot of catheter and corresponding vertical shadow disappear from image
In longitudinal or oblique view, gently manipulate catheter to see tip move in and out of image
The correct catheter tip position is just distal to the ostium of the superficial epigastric vein, or 1-2 centimeters from the saphenofemoral junction, if the SEV is not identified.
A longitudinal or oblique view of the common femoral vein, saphenofemoral junction, and great saphenous vein provides the most accurate visualization of the tip placement. Because there are no expanding electrodes as a landmark it is important to perform a secondary verification of tip position by scanning from proximal thigh to SFJ in transverse to detect the true distal end of the catheter and see the transition where the catheter disappears from the image.
Once proper catheter tip placement is confirmed, tumescent fluid is injected around the SFJ.

23. Anatomical structures on colour facility

24. Small Saphenous Vein (SSV)
Courses from lateral ankle up posterior calf
Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ)
Variable confluence with Popliteal Vein (PV)
Proximal portion lies between superficial & deep fascial layers
SPJ
Pop V
SSV
Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.

25. Anatomical structures on colour facility

26. Detection of reflux on colour facility

27. Detection of reflux on colour facility

28. Detection of reflux on colour facility

29. Detection of reflux on colour facility
Perforating vein
If reflux is present measure the diametre but this cannot distinguish competent from incompetent
Duration of reflux

30. Detection of reflux on Doppler
Reflux is present when retrograde flow lasts for at least 1 sec

31. Patient selection for Endovenous Alation
Identification of all refluxing venous segments and their ablation is the key to minimise recurrence
Diametre of central GSV > 15 mm may be associated with thrombus extension to CFV
Uncorrectable coagulopathy
Liver dysfunction limiting local anaesthetic use
Immobility
Pregnancy
Breastfeeding

32. Contraindication
Thrombus in the vein segment to be treated

33. Choosing the Closure Candidate
Preoperative ultrasound evaluation
Reflux > 0.5 seconds in superficial venous system
Assess GSV, noting:
Vein depth and maximum diameter
Presence of tortuous or aneurysmal segments
Other significant anatomy
Duplicate systems
Large side branches
Incompetent perforators or tributaries

34. If vein lies superficially, close to skin the ablation may cause burn
Vein depth from the skin: Why is so important?
The aim of ablation procedures is to damage the inner vein wall without causing a full-thickness burn, which could lead to perforation of the vein resulting in bruising or haematoma formation
If vein lies superficially, close to skin the ablation may cause burn

35. Pre-op Ultrasound Assessment
Map and mark
Maximum diameter
Tortuous segments
Aneurysmal segments
Areas where vein is very close to skin
Large branches or perforators
Potential access sites

36. Infiltration Technique
Do not leave any vein segments unprotected
Re-scan to ensure:
>10 mm distance between skin surface and vein wall
Circumferential black “halo” appearance in fascial compartment
Perivenous vs. subcutaneous infiltration
Image courtesy of Carolyn Menendez, MD
During endovenous ablation procedure, if patient experiences discomfort, energy delivery can be stopped and additional tumescent fluid can be administered – as long as within patient’s dosage limits – and the procedure resumed
If dosage limit has been met, plain injectable saline may be used in place of tumescent anesthesia

37. Vein Mapping Make indentions in skin using a straw
Remove US gel from leg
Connect marks on leg with marker to identify pathway of vein and important anatomy
Image courtesy of Nick Morrison, MD

38. Pre-op Descending Venography

40. Selective descending ovarian and hypogastric venogram
Significant ovarian vein reflux but
No hypogastric vein reflux was detected

41. Hypogastric vein reflux
Ovarian vein reflux

42. Descending Ovarian Venogram 4 weeks after embolisation

43. Hypogastric vein embolisation

44. CT venography

45. Chronic Venous Obstruction

46. DP=8 mmHg
DP=22 mmHg
DP=2 mmHg

47. IVC filter placement Indications
DVT and covtraindication for anticoagulation
Reccurent PE being on adequate anticoagulation
Pre-procedural evaluation
MR or CT venography is required for IVC and iliac vein patency and IVC diametre measurement

48. Thank you for your attention